coming off antidepressants
===
Welcome to Joy Lab!: [00:00:00] Welcome to the Joy Lab podcast, where we help you uncover and foster your most joyful self. Your hosts, Dr. Henry Emmons and Dr. Aimee Prasek, bring you the ideal mix of soulful and scientifically sound tools to spark your joy, even when it feels dark. When you're ready to experiment with more joy, combine this podcast with the full Joy Lab program over at JoyLab.coach
Hello, I'm Henry Emmons and welcome to Joy Lab.
Aimee: And I'm Aimee Prasek. Here at Joy Lab, we infuse science with soul to help you build your resilience and uncover your joy. And today we are talking about what it's like to come off antidepressants. This is such an important conversation, I think, because it is such a common experience coming off meds, but there isn't a whole lot of conversation around it.
So in 2021, there was a Cochrane [00:01:00] review, ~uh,~ that could identify only 33 randomized control trials looking at folks coming off of antidepressants, a total of 33. And I think they found more than a thousand studies on starting them. So you can kind of see where the priority is in the research. This is just not a priority.
~Uh,~ Thankfully a recent study looked into this experience of coming off antidepressants and I really appreciated the methodology of it. Just to geek out for a moment. Uh, this was a qualitative study, so it wouldn't have been put into that group of 33. And they used a phenomenological approach. So this is really where folks share their lived experience.
And then the researchers are using those lived experiences in an attempt to create a larger narrative. I can kind of describe the experience more generally for a larger population of people. And I think this type of research approach, ~this methodological,~ [00:02:00] this methodological approach is underutilized in healthcare research.
Patient voices should be more prominent in healthcare. That's a shocking statement, right? Uh, I think that lack of voice is another reason why experiences like coming off medication are just so under discussed. Like, the mic isn't even given. And when medications are being tested for effectiveness and safety, rarely do participants get to share their experiences beyond just checking off some side effect boxes.
So this is important to talk about.
Henry: Yeah, I totally agree. And that study caught my eye too, partly because I see so much of this in my own clinical practice. I swear if I chose to, I could fill my entire practice with helping people get off of medications. This is not a new concept, you know, we have known [00:03:00] about serotonin, reuptake inhibitor SSRI) withdrawal, for decades. And so it really surprises me, sometimes I am shocked actually, at how few people, including prescribing doctors, seem to know how bad this can be, or how to deal with it. So I just can't tell you how often I see somebody who was stable taking an antidepressant that they'd been on for years.
And partly because they felt good, they felt stable, didn't feel they needed to take it any longer, so they wanted to come off of it. And sometimes folks just decide on their own to stop it, or sometimes they're instructed by their doctor to taper it over a period of a week or two. And either way, they might feel fine at first, and then things fall apart, and sometimes fall apart in a really [00:04:00] big way.
Aimee: Yeah. ~Um, I want to,~ I want to talk about how things can fall apart, ~uh,~ in a bit, but first, you did note tapering. So understanding that this is again, not a replacement for advice from your doctor. Let's talk about tapering antidepressants. I want to hear what you have to say here, Henry, because I'm interested in what's happening around hyperbolic tapering.
And if you have thoughts on that, but also just in general, to mirror what you just said as well, I've had so many people tell me through the years that~ you know,~ coming off antidepressants was really rough, or, and, that their GP didn't even instruct them to taper their antidepressant. I just had somebody recently come to me, and they had been taking an antidepressant for 20 years, and there was no tapering.
And it was bad news.
So coming off of it. ~Um,~ So it certainly depends on the type of medication, the duration of use, the person, but, can you give us just some best practices [00:05:00] for us that, you know, we can be aware of and maybe share with our care team if need be?
Henry: Sure. So, ~you know,~ very simplistically, what I think happens here is that after taking something for a long enough period of time, your brain gets used to it. And you've created a new normal, a new homeostasis. And it takes a long time. for the brain to change back from that new normal. So I think it can take six to 12 months for the change to occur in the first place.
So that's kind of my, my time frame to think about how long, if a person has been on this medication more than a year, let's say, then ~we,~ we want to be careful about how we taper it. If it's more than five or ten years, then we need to be so careful about how to taper it. So I think that, ~you know,~ if people are on these meds short term, meaning just a few months, [00:06:00] usually they're not that hard to come off of, but still they should be tapered, perhaps over a period of a few weeks, like maybe a month or so.
~So~ That's in the best case scenario in somebody who's only been on the medication for ~You know,~ maybe six months. But people have been on them for years. The tapering process might take several months. It might take up to a year or more. You mentioned a term, Aimee, ~um,~ hyperbolic tapering. Do you want to just share what that means?
Aimee: Yeah. It's coming. There's a lot more of it in the research now looking at, ~uh, transcripts. ~a practice or protocol, I would say, of tapering that it's sort of,~ um,~ you can imagine a playground slide. ~There's sort of a, um, you know,~ as you get closer to zero, you have a smaller and smaller reduction in dose. So you might have, ~um, you know,~ a little bit more, ~um,~ reduction in dose at the top, at the beginning, and then you just continue to extend that tapering [00:07:00] duration for, depending on the person, it might be quite a while then when you continue to maybe half it or, ~um, you know,~ cut it by even 10%. So everybody's different and there's a lot of research on this. So I'd love to know how maybe you work in that way, perhaps, because I've heard you talk about it, maybe not with that term.
Henry: Yeah, I, but I've been doing that for quite a long time, largely because of seeing what happens to folks who try to come off of these too quickly. And I am just not a believer in this having to be a very painful process that, ~you know,~ throws people into instability
and forth.
~So,~ So ~I,~ I think it makes sense to taper at whatever pace the person needs to be tapered in order ~to, ~to remain,~ you know,~ relatively stable and symptom free. Relatively. There might be, not be any way to do it 100 percent perfectly. ~ ~So, ~um, I,~ I might separate this into ~like~ three different patterns.
There are some people I would do a [00:08:00] very quick short taper, meaning it might just be a few days to a couple of weeks. And that would be someone who, who is just new on a medication and it's causing a lot of problems. ~You know,~ So ~they're,~ they're having a lot of side effects. They don't want to stay on it.
Even then, it's usually a good idea to taper rather than just stop. So you might~ you know, ~reduce the dose ~in,~ in half for a few days and then a quarter for a few days and then come off if it's a really quick taper because they're not doing well. That's really, if they've only been on it a short time. An intermediate taper where maybe they've been on it just a few months, it did its job, they don't need it anymore.
Then I might do it over a period of three to four weeks, possibly up to eight weeks, where maybe we would go down to three quarters of the dose for a week or so and then a half the original dose and so forth. But the people who have been on these for long periods of time and then [00:09:00] need to come off for whatever reason, then we might do something like this hyperbolic tapering.
So for example, we might try and reduce by about 10 percent each time we cut the dose down. And so let's just say for example, you're starting with a hundred milligrams of a drug like Zoloft or Sertraline. So 10 percent would be ~you know, in~ about a 10 milligram dose per reduction. Now, just for practical purposes, because of how the tablets come, I might do it a little quicker at first, you know, maybe we'd go down by 12 and a half milligrams, for example But the point being that it's, it's pretty gradual But when you get below let's say 50 percent of where you started, so now you're down to 50 milligrams then that might need to slow it down
and maybe we go down in you know 5 milligram increments and when you get down to 25 milligrams, 25 percent or [00:10:00] less, we might need to do it even slower.
So this can take a while and in order to get those really tiny increments at the very near the end of the taper, it's hard to do that because they don't come in those sizes, you know, the
Yeah. the pills don't
Aimee: It's not made for the process.
Henry: It's not made for that process at all.
Aimee: Right.
Henry: I have had patients cut off little slivers of a tablet. I've even had people, if it's a capsule like a drug like venlafaxine or effexor, I've had people open the capsule, count all the little pellets, little grains in there, and then gradually reduce the number of little granules that they take per day. And it's just a
Aimee: a
Henry: laborious process.
Aimee: lab coat and a chemistry set.
Yeah, it's, it could be better.
Henry: So ~if, ~if possible, if the medication is available as a liquid, it's much easier because you can do it in [00:11:00] really small increments.
If it's not available as a liquid, sometimes we'll go to a compounding pharmacy
where they can make different size, ~you know,~ tablets or capsules and do it at that really gradual pace. But like I said, it might take, Six months to, ~uh,~ even
up to a year and a half to get off these medications safely.
Aimee: Yeah, this is not jumping off the swing, right? This is going down a long slide
for many folks. ~Um,~ And I like this research coming out on this too, because hopefully this will inform some new products. ~Um,~ There's tapering strips and like you said, liquids. So as this research comes about and if we're seeing efficacy from these protocol, then we can start to get these products in a proper form so that folks can taper.
And it's easy. Part of the, just as you noted, Henry, it's just hard to go down slowly when you're trying to chop a tablet into a
Henry: [00:12:00] right,
Aimee: 60th of its original size.
Henry: right.
Aimee: ~Um,~ All right, so let's, let's pivot a bit into ~um,~ this experience then of coming off of antidepressants. And I don't want this to be an anxiety producing episode for folks either who are wanting to come off medications.
~Uh,~ But it is estimated that 50 percent of folks will have withdrawal symptoms. So there's that. ~Um,~ We've talked about maybe some more,~ um,~ appropriate ~taping,~ tapering strategies,~ um,~ that can probably reduce that number, I would say, ~uh, ~but there's, right. So if it's done properly, ~um, you know,~ there's again, more work coming out on that.
But Henry, can you then talk honestly, about what you've seen related to these withdrawal reactions. What are some things folks can expect,
Henry: Yep.~ ~
Aimee: ~um,~ or look out for?
Henry: Yeah. So, I, I think it's worth saying first that this is ~It's~ very much an individualized process and there [00:13:00] are people, ~um, it's, it's,~ it astounds me, but there are folks who can stop a drug suddenly and have no problem whatsoever.
That's great when that happens. I don't know what the percentage is ~of, ~of times that that happens, especially folks who've been on these drugs for years, but it does happen.
Not everybody has ~this,~ this bad withdrawal stuff. and to your point, Aimee, I think that if this is done slowly, gradually, ~the,~ the percentage of folks who have really bad withdrawal symptoms can go way, way down.
Aimee: Yeah.
Henry: But I would, wouldn't promise anybody that they wouldn't have any withdrawal symptoms.
~Uh,~ it's just a question of how strong they might be and are they just little minor annoyances or is it a big deal?
So the minor annoyances are things like, ~you know,~ maybe just getting some headaches or feeling a little funky, almost like~ you're,~ you have a mild illness or something, disrupting sleep slightly or appetite slightly. [00:14:00] I mean, it's not uncommon to have some physical withdrawal symptoms. And if it's tapered relatively slowly, those are not usually a big deal. And those usually happen pretty quickly. Like if you stop a medication today, just stop it, it'll happen within the first couple of weeks, usually. The bigger problem, in my view, is the emotional withdrawal symptoms. That can really hit people hard. And it usually comes a little bit later. ~So~ I often hear people say, "I stopped the meds, and at first I felt great."
And then,~ you know,~ three weeks, a month, two months later, it's like they got hit by a truck and they feel just awful emotionally. That's if they've stopped it too quickly. And so it can feel in some ways like there's a rebound of the original problem. Whatever it was, anxiety, depression, and some folks I think probably accurately feel even worse than they did [00:15:00] in the first place.
~You know,~ It can be very destabilizing of the mood. And I think it's really important to remember that even though anxiety and depression are not purely brain chemical problems, withdrawing from medications is pretty much a brain chemical problem. I mean ~it's,~ it's not anybody's fault. It's not because ~ you're, you're,~ you aren't handling stress right, you're not doing things wrong.
It's just that it's very destabilizing for your brain chemistry and that can throw your mood off in a big way.
So a lot of times it's just feeling kind of emotionally raw, as if you just can't stand any minor stressful thing in your life without really being thrown off into a really unpleasant state of emotions.
It can throw off sleep, which only makes things worse ~um, you know,~ and it, it can make some people feel really, really [00:16:00] restless or agitated. So, you know, ~it's,~ at its worst, this is really not, not a good feeling, a good thing to experience at all. Probably not as bad as coming off some drugs like ~um, you know,~ alcohol or the benzodiazepines like valium and Ativan, but because those are those that can be life threatening.
In this instance It's not life threatening unless the mood is really really terrible, but it but it still can be really, really unpleasant.
Aimee: ~Sorry, there's something I was gonna ask you and I totally forgot. Um, Oh, yeah. Okay. Cut that blink spot out there, Ellie. Um,~ I think also just to note something that is really hard- you spoke to just the pure brain chemistry of this, of, of coming off. I think there's also the feeling as you come off and if it's, hasn't been tapered or you're experiencing this with these withdrawal reactions, just the feeling of like, "I was doing so well."
Yeah,
it's just like a punch in the gut.
Henry: right
Aimee: All that work or, you know, it hits you. ~Um,~ So is that something too, that you hear a lot from your [00:17:00] patients? Just that maybe a frustration or...
Henry: yes, absolutely. Or a fear that, you know, this illness that they thought had really been in the, put in their past is rearing its ugly head again. You know, it can be so scary to go through this. And, and it's just as helpful ~to,~ to try to realize this is pure and simple withdrawal. It does not mean that you have the original illness again.
It does not mean that you have to stay on a medication forever. It just means that ~you're,~ you're experiencing withdrawal either because you're coming off the med too quickly or because you're one of those folks that you know, it's going to cause withdrawal symptoms no matter what. But there are things people can do to support themselves during this time.
We should talk a little bit about that too. So one of the things is to slow it down in the ways we've been talking about. Work with someone who's really experienced [00:18:00] and understands what this is and how to deal with it. So you go at a pace that is really tolerable for you.~ Um,~ I think it's helpful to do as many things as you can, ~other, ~other kinds of things to support your serotonin system, because usually this is happening with the serotonin drugs.
~It's,~ It's basically the SSRIs that are, ~or,~ or another serotonin agent that causes this problem. So we have a whole host of things people can do naturally to boost or support their serotonin system listed ~in our,~ on the natural mental health website. And please, ~you know,~ go ~and ~ and take advantage of all of those things that you can.
One of the most, the more powerful ways to do that is through the supplement 5-HTP, which we have talked about in a recent podcast. It's the serotonin boosting supplement along with some essential cofactors, other ingredients [00:19:00] that support making serotonin like some of the B vitamins and magnesium. So physiologically think about how to support yourself too.
Plus there's a lot of really good~ Plus there's a lot of really good behavioral things you can do that we'll list in the show notes and you can, you can find on our website. ~
Aimee: ~Oh, you cut out on that last piece, Henry. ~
Henry: ~You know, I did, I ~
~did touch my, my microphone just with my hand. So let me, uh, let me see. ~
Aimee: ~yeah. ~
Henry: ~So yeah, so there's just~ things that people can do to support their brain chemistry and also some behavioral things that we will list in our show notes and we have ~them, um,~
a whole host of things ~on our,~ on our website too. ~ ~
Aimee: ~Yeah. There you go, Ellie. Um, so you can fix that here.~ Yeah, I will link to those things in the, ~uh,~ show notes, folks. Um, you know, I, I just really hope this conversation has been helpful. This is hopefully information you can take to your doc, you know, what, what Henry just noted too, the 5-HTP, talking with your doctor about that, tapering strategies, but just this awareness, I think, is powerful as well. This conversation. So share this episode with folks who you think might be in this situation. I just think it's so important, ~um,~ when you're coming off antidepressants to have [00:20:00] some more information to know what the experience can be like and how you can make it easier because it shouldn't be terrible, as you said, Henry.
To close, I just want to share some love, some wisdom from author Gabrielle Calvocoressi. It's such a feel good reminder. So here's what they wrote. Please soak in it. ~ Dance until your blo I'm gonna start that over.~ "Dance until your bones clatter. What a prize you are. What a lucky sack of stars."
Thanks for joining us!: Thank you for listening to the Joy Lab podcast. If you enjoy today's show, visit JoyLab.coach to learn more about the full Joy Lab program. Be sure to rate and review us wherever you listen to your favorite podcasts.
Please remember that this content is for informational and educational purposes only. It is not intended to provide medical advice and is not a replacement for advice and treatment from a medical professional. Please consult your doctor or other qualified health professional before beginning any [00:21:00] diet change, supplement, or lifestyle program.
Please see our terms for more information.
